Transcript It’s Not All About Evidenced

It’s Not All About
Evidenced-Based Practice
Michael S. Levy, Ph.D.
Director of Clinical Treatment Services
CAB Health & Recovery Services, Inc.
American Psychological Association
August 11, 2006
Evidence-Based Practice is One Aspect of
Delivering Quality Care
Therapeutic
Relationship, 30%
Extratherapeutic
Change, 40%
Expectancy
(placebo effects),
15%
Techniques, 15%
Lambert, M.J. (1992). Implications of outcome research for psychotherapy
integration. In J.C. Norcross & M. R. Goldstein (Eds.), Handbook of
Psychotherapy Integration (pp. 94-129). New York: Basic Books.
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Evidence-Based Practice is One Aspect of
Delivering Quality Care
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On the basis of the Horvath and Symonds (1991) meta-analysis, Wampold
(2001) portioned 7% of the overall variance of outcome to the alliance.
Putting this into perspective, the amount of change attributable to the
alliance is about seven times that of specific model or techniques.
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Conservative estimates indicate that between 6% (Crits-Christoph et al.
1991) and 9% (Project MATCH research Group, 1998) of the variance in
outcomes is attributable to therapist effects, whereas treatment context
accounts for up to 3% to 4% (Wampold, 2001).
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From Duncan and Miller. Does Manualization Improve Therapy Outcomes?
(pp. 131-160). In Norcross, Beutler, and Levant. (2006). Evidenced Based
Practices in Mental Health, 2006.
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Evidence-Based Practice is One Aspect of
Delivering Quality Care
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In looking at individual drug counseling (IDC) in NIDA’s
Collaborative Cocaine Treatment Study, it was found that in cases
when the alliance was strong, counselor adherence did not much
matter; those patients typically improved. However, for cases in
which the alliance was weak, adherence did matter. Those patients
improved more when their counselors adhered moderately to IDC
principles than when the counselors were either minimally or highly
adherent.
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From Barber, et al. (2006). The role of therapist adherence,
therapist competence, and alliance in predicting outcome of
individual drug counseling: Results from the National Institute
Drug Abuse Collaborative Cocaine Treatment Study. Psychotherapy
Research, 16, 229-240.
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Evidence-Based Practice is One Aspect of
Delivering Quality Care
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NIDA’s Principles of Drug Addiction Treatment:
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No single treatment is appropriate for all individuals.
Treatment needs to be readily available.
Effective treatment attends to multiple needs of the
individual, not just his or her drug use.
An individual’s treatment and services plan must be
assessed continually and modified as necessary to ensure
that the plan meets the person’s changing needs.
Remaining in treatment for an adequate period of time is
critical for treatment effectiveness.
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Evidence-Based Practice is One Aspect of
Delivering Quality Care
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Counseling (individual and/or group) and other
behavioral therapies are critical components of
effective treatment for addiction.
Medications are an important element of treatment
for many patients, especially when combined with
counseling and other behavioral therapies.
Addicted or drug-abusing individuals with coexisting
mental disorders should have both disorders treated in an
integrated way.
Medical detoxification is only the first stage of addiction
treatment and by itself does little to change long-term
drug use.
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Evidence-Based Practice is One Aspect of
Delivering Quality Care
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Treatment does not need to be voluntary to be effective.
Possible drug use during treatment must be monitored
continuously.
Treatment programs should provide assessment for
HIV/AIDS, Hepatitis B and C, tuberculosis and other
infectious diseases, and counseling to help patients
modify or change behaviors that place themselves or
others at risk of infection.
Recovery from drug addiction can be a long-term process
and frequently requires multiple episodes of treatment.
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Evidence-Based Practice is One Aspect of
Delivering Quality Care
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The point, though, is not convincing you or anyone else of
the merits of using EBPs.
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Rather, the point is that when trying to deliver quality care in
a substance abuse treatment organization, there are so many
other things to think about and to focus on in order to ensure
quality treatment. And it isn’t all about evidenced based
practices.
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Frustrations and Realities of Implementing
EBPs
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Most EBPs focus on the outpatient realm, which is a much
more circumscribed treatment intervention.
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The energy it takes to focus on fidelity monitoring is
enormous and what has been found to be effective with
careful monitoring may not be a reality in a community
setting.
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Staff turnover issues
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The costs may be immense
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The Bottom Line: Where Should I Place My
Energies?
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Client Satisfaction:
 You can have the greatest EBPs in the world in your
program. Yet with poor client satisfaction, the client’s
entire treatment experience will be destroyed.
 In a residential program for about 85 homeless men with
SUDs, on a scale of 1-4, overall satisfaction was 2.6.
When asked if they would refer someone to the program,
only 60-65% stated that they would. Finally, treatment
completion rates were about 30%. There were many
complaints of disrespectful and unprofessional staff. And
this can be maintenance, secretarial, direct care, or
kitchen staff.
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The Bottom Line: Where Should I Place My
Energies?
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Created trainings on power and powerlessness using the
Stanford Prison Experiment Video.
Conducted other trainings on customer satisfaction
(quality care).
We consistently bring both positive and negative feedback
to staff and address identified issues.
Overall satisfaction is now about 3.2 and consistently over
90% of clients would refer someone to the program.
Treatment completion rates are now 56%. And very few
complaints of disrespectful and unprofessional staff.
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Getting people to even come to treatment:
if they don’t come, they won’t get help.
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We found in our outpatient office that in general, of 100
intake appointments, only 53 came (47% no show rate),
and of those, only 32 returned for another appointment
(40% no return rate).
Developed quality improvement projects to decrease no
show rates and to increase the number of people who
returned for follow up.
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Getting people to even come to treatment:
if they don’t come, they won’t get help.
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Spoke with clients about transportation concerns.
Spoke with clients directly who were referred from
hospitals and detoxification programs.
Scheduled clients more quickly.
Created an orientation brochure and reviewed it with
clients.
Called back clients when they did not show for treatment.
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Getting people to even come to treatment:
if they don’t come, they won’t get help.
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Over five months, we decreased our intake no show rate to
22% and decreased our no return rate for a follow up
appointment to 27%. So now, of 100 intake appointments,
78 come and of those, 57 return.
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Next plan is to begin a patient feedback system in which
clinicians get real time feedback about the quality of their
alliances with their clients.
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Increasing treatment retention – if clients don’t
stay in treatment, they won’t get better.
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In our detoxification programs, treatment completion was about 53%.
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Developed many projects to see if we can increase the rates of
treatment completion. These included:
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Having counselors touch with clients the day of admission, even
if they couldn’t meet with them for the psychosocial assessment
Introducing new clients to the charge nurse
Creating a drop off box
Contingency Management
Adding more recreational time
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Increasing treatment retention – if clients don’t
stay in treatment, they won’t get better.
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Were able to increase treatment completion to 65%.
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Of those who complete treatment, 25-30% go on for further
residential treatment.
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Among those that do not complete treatment, the percentage
is ZERO.
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Getting People in the Door in a Timely Way
Within our Methadone Treatment Program, we found that the
time from first phone call to time of first dose of methadone
was 18 days.
 Increased lab time
 Increased nurse practitioner and physician time
 Made getting clients in the door more quickly an
important focus
 Increase intake slot appointments
 Developed a tracking system
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We decreased this time to an average of 8 days.
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Ensuring Clients Get the Treatment They
Need
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On a weekly basis, we review all new admissions in our
outpatient office and review the ASI, treatment plans, and
progress notes to ensure that treatment needs and services
needed are, in fact, provided and received.
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Feedback is given back to clinicians.
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Summary
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Concern is that providers’ focus is and will be primarily
concerned with implementing evidence- based practices.
While important, this can result in less focus on other
aspects of quality care.
These other aspects of care are every bit, if not more
important.
These other elements of care must not be forgotten in
the ethos of demanding the implementation of EBPs.
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